Health service use of infants involved in family justice care and supervision proceedings in Wales: a longitudinal national data linkage study

ObjectiveWhen an infant is identified as having suffered or is at risk of suffering significant harm from parents or caregivers, section 31 care and supervision proceedings  (s.31, Children Act 1989) may be issued. We examined the healthcare use of infants under one year old subject to these proceedings in Wales. ApproachA retrospective e-cohort study utilising data held in the Secure Anonymised Information Linkage (SAIL) Databank. General Practice records, emergency department attendances, and hospital admissions (non-elective and elective) were linked with family justice (Cafcass Cymru) data between 2011–2020 for all s.31 proceedings (n = 920). By comparing to the infant population not undergoing family law proceedings (n = 18179), regression models examined the incidence and rate of healthcare events between birth and the court proceeding application date. Wider determinants of health were sequentially added (infant perinatal factors, maternal mental health, sex, area-level deprivation). Reasons for healthcare events were also investigated. ResultsThese models showed that infants who were subject to s.31 care and supervision proceedings were more likely to have required healthcare prior to proceedings than the comparison group. A similar pattern was shown for the rate of healthcare events. Even when wider determinants of health were included in the models, this difference was especially pronounced for incidence and event rate ratios for emergency department attendances, [incidence RR = 1.73, CI =  1.52–1.96; event RR = 2.08, CI = 1.82–2.38] and non-elective inpatient admissions [incidence RR = 2.91, CI = 2.57–3.28; event RR = 3.84, CI = 3.31–4.45]. Infants in s.31 proceedings were more likely to require healthcare for injury and poisoning, and other external causes. ConclusionThis is the first population-wide evidence on the health of infants subject to s.31 care and supervision proceedings in Wales. These findings highlight the increased healthcare utilisation for this population. The study helps to build a better understanding of the needs and vulnerabilities of infants in the family justice system.

A population-level study into health vulnerabilities of mothers and fathers involved in public law care proceedings in Wales, UK

ObjectivesUnder section 31 (s.31) of the UK Children Act 1989, public law care proceedings can be issued if there is concern a child is subject to, or at risk of significant harm. We examined health vulnerabilities of parents involved in public law care proceedings in the two-year period prior to involvement. ApproachOur study created an anonymised individual-level population-based cohort, with a matched comparison group of parents in Wales who were not subject to care proceedings, matched on age, sex and deprivation. Family court data provided by Cafcass Cymru were linked to population-level healthcare records held within the Secure Anonymised Information Linkage (SAIL) Databank. Demographic characteristics, overall health service use and health profiles of parents of children subject to s.31 care proceedings between 2011 and 2019 were examined. ResultsData were available for 8,821 parents involved in care proceedings between 2011 and 2019, with a comparison group of 32,006 parents. Nearly half (47.6%) of cohort parents resided in the most deprived quintile. Higher levels of healthcare use were found for cohort mothers and fathers compared to the comparison group across multiple healthcare settings, with the most pronounced differences for emergency department attendances (59.3% vs 37.0%). Health conditions with the largest variation between groups were related to mental health (43.6% vs 16.0%), substance use (19.4% vs 1.6%) and injuries (41.5% vs 23.6%). ConclusionThis study highlights the heightened socioeconomic and health vulnerabilities of parents who experience care proceedings concerning a child. Better understanding of the needs and vulnerabilities of this population may provide opportunities to improve a range of support and preventative interventions that respond to crises in the community.

A population level study into health vulnerabilities of mothers and fathers involved in public law care proceedings in Wales, UK between 2011 and 2019

IntroductionUnder section 31 of the Children Act 1989, public law care proceedings can be issued if there is concern a child is subject to, or at risk of significant harm, which can lead to removal of a child from parents. Appropriate and effective health and social support are required to potentially prevent some of the need for these proceedings. More comprehensive evidence of the health needs and vulnerabilities of parents will enable enhanced response from family courts and integrated other services. ObjectiveTo examine health vulnerabilities of parents involved in care proceedings in the two-year period prior to involvement. MethodsFamily court data provided by Cafcass Cymru were linked to population-based health records held within the Secure Anonymised Information Linkage Databank. Linked data were available for 8,821 parents of children involved in care proceedings between 2011 and 2019. Findings were benchmarked with reference to a comparison group of parents matched on sex, age, and deprivation (n = 32,006), not subject to care proceedings. Demographic characteristics, overall health service use, and health profiles of parents were examined. Descriptive and statistical tests of independence were used. ResultsNearly half of cohort parents (47.6%) resided in the most deprived quintile. They had higher levels of healthcare use compared to the comparison group across multiple healthcare settings, with the most pronounced differences for emergency department attendances (59.3% vs 37.0%). Health conditions with the largest variation between groups were related to mental health (43.6% vs 16.0%), substance use (19.4% vs 1.6%) and injuries (41.5% vs 23.6%). ConclusionThis study highlights the heightened socioeconomic and health vulnerabilities of parents who experience care proceedings concerning a child. Better understanding of the needs and vulnerabilities of this population may provide opportunities to improve a range of support and preventative interventions that respond to crises in the community.

A population level study into health vulnerabilities of mothers and fathers involved in public law care proceedings in Wales, UK between 2011 and 2019

Introduction

Under section 31 of the Children Act 1989, public law care proceedings can be issued if there is concern a child is subject to, or at risk of significant harm, which can lead to removal of a child from parents. Appropriate and effective health and social support are required to potentially prevent some of the need for these proceedings. More comprehensive evidence of the health needs and vulnerabilities of parents will enable enhanced response from family courts and integrated other services.

Objective

To examine health vulnerabilities of parents involved in care proceedings in the two-year period prior to involvement.

Methods

Family court data provided by Cafcass Cymru were linked to population-based health records held within the Secure Anonymised Information Linkage Databank. Linked data were available for 8,821 parents of children involved in care proceedings between 2011 and 2019. Findings were benchmarked with reference to a comparison group of parents matched on sex, age, and deprivation (n = 32,006), not subject to care proceedings. Demographic characteristics, overall health service use, and health profiles of parents were examined. Descriptive and statistical tests of independence were used.

Results

Nearly half of cohort parents (47.6%) resided in the most deprived quintile. They had higher levels of healthcare use compared to the comparison group across multiple healthcare settings, with the most pronounced differences for emergency department attendances (59.3% vs 37.0%). Health conditions with the largest variation between groups were related to mental health (43.6% vs 16.0%), substance use (19.4% vs 1.6%) and injuries (41.5% vs 23.6%).

Conclusion

This study highlights the heightened socioeconomic and health vulnerabilities of parents who experience care proceedings concerning a child. Better understanding of the needs and vulnerabilities of this population may provide opportunities to improve a range of support and preventative interventions that respond to crises in the community.

Anxiety and depression among children and young people involved in family justice court proceedings: longitudinal national data linkage study

BACKGROUND

Little is known about mental health problems of children and young people (CYP) involved with public and private law family court proceedings, and how these CYP fare compared to those not involved in these significant disruptions to family life.

AIMS

This study examined records of depression/anxiety in CYP involved in public and private law proceedings using linked population-level data across Wales.

METHOD

Retrospective e-cohort study. We calculated the incidence of primary-care-recorded depression/anxiety among CYP involved in these proceedings and in a comparison group, using Poisson regression. Depression/anxiety outcomes following proceedings were evaluated using pairwise Cox regression, with age- and gender-matched controls of CYP who had no involvement with the courts.

RESULTS

CYP in the public group had twice the risk of depression (adjusted incidence rate ratio aIRR = 2.2; 95% CI 1.9-2.6) and 20% higher risk of anxiety (aIRR = 1.2; 95% CI 1.0-1.5) relative to the comparison group. The private group had 60% higher risk of depression (aIRR = 1.6; 95% CI 1.4-1.7) and 30% higher risk of anxiety (aIRR = 1.3; 95% CI 1.2-1.4). Following private law proceedings, CYP were more likely to have depression (hazard ratio HR = 1.9; 95% CI 1.7-2.1), and anxiety (HR = 1.4; 95% CI 1.2-1.6) than the control group. Following public proceedings, CYP were more likely to have depression (HR = 2.1; 95% CI 1.7-2.5). Incidence of anxiety or depression following court proceedings was around 4%.

CONCLUSIONS

Findings highlight the vulnerability of CYP involved in family court proceedings and increased risk of depression and anxiety. Schools, health professionals, social and family support workers have a role to play in identifying needs and ensuring CYP receive appropriate support before, during and after proceedings.

Maternal health, pregnancy and birth outcomes for women involved in care proceedings in Wales: a linked data study

BACKGROUND

Under the Children Act 1989, local authorities in Wales, UK, can issue care proceedings if they are concerned about the welfare of a child, which can lead to removal of a child from parents. For mothers at risk of child removal, timely intervention during pregnancy may avert the need for this and improve maternal/fetal health; however, little is known about this specific population during the antenatal period. The study examined maternity characteristics of mothers whose infants were subject to care proceedings, with the aim of informing preventative interventions targeted at high risk mothers.

METHODS

Anonymised administrative data from Cafcass Cymru, who provide child-focused advice and support for family court proceedings in Wales, were linked to population-based maternity and health records held within the Secure Anonymised Information Linkage Databank. Linked data were available for 1111 birth mothers of infants involved in care proceedings between 2015 and 2018. Findings were benchmarked with reference to an age-deprivation-matched comparison group (n = 23,414), not subject to care proceedings but accessing maternity services during this period. Demographic characteristics, maternal health, reproductive history, interaction with midwifery services, and pregnancy and birth outcomes were examined. Descriptive and statistical tests of independence were used.

RESULTS

Half of the women in the cohort (49.4%) resided in the most deprived areas. They were more likely to be younger at entry to motherhood (63.5% < 21 years-of-age compared to 42.7% in the comparison group), to have mental health (28.6% compared to 8.2%) and substance use issues (10.4% compared to 0.6%) and to smoke (62.7% compared to 24.8%) during pregnancy. The majority first engaged with maternity services within their first trimester of pregnancy (63.5% compared to 84.4%). Babies were more likely to be born preterm (14.2% compared to 6.7%) and, for full-term babies, to have low birthweights (8.0% compared to 2.8%).

CONCLUSION

This novel linkage study highlights multiple vulnerabilities experienced by pregnant mothers who have experienced care proceedings concerning an infant. Policy and practice colleagues require a clearer picture of women's needs if child protection and health services are to offer effective services which prevent the need for family court proceedings and infant removal.

Antenatal risk factors for child maltreatment: Linkage of data from a birth cohort study to child welfare records

BACKGROUND

Understanding the risk factors for child maltreatment is critical to efforts to reduce its prevalence.

OBJECTIVE

This study investigated the association between characteristics and circumstances of mothers during pregnancy and the subsequent identification of concerns about child maltreatment.

PARTICIPANTS AND SETTING

The study drew on two data sets: (i) data from questionnaires administered to the expectant mothers of 11,332 children born in a deprived multi-ethnic local authority in England between 2007 and 2011, for a birth cohort study, and (ii) administrative data on children referred to child welfare services.

METHODS

The linkage of these two pre-existing data sets enabled the prospective study of risk factors for child maltreatment.

RESULTS

A range of factors captured during the antenatal period were associated with an increased likelihood of subsequent recorded child maltreatment concerns, including: younger maternal age (HR=0.96; p < .001), lower maternal education level (HR=1.36; p < .001), maternal mental illness (HR=1.17; p = .001), maternal smoking in pregnancy (HR=1.69; p < .001), single motherhood (HR=1.41; p = .022), larger family size (HR=1.13; p < .001), multiple deprivation (HR=1.01; p = .011), social housing (HR=1.72; p < .001), paternal unemployment (HR=1.79; p < .001), and the receipt of means-tested welfare benefits (HR=1.43; p < .001). A greater total number of risk factors during pregnancy also increased the risk of subsequent maltreatment concerns (HR=1.45; p < .001).

CONCLUSIONS

The identification of multiple risk factors in this study supports claims that single targeted interventions are unlikely to be successful in preventing or reducing child maltreatment due to its multifactorial nature, and that multidimensional interventions are required.

Data Resource: population level family justice administrative data with opportunities for data linkage

INTRODUCTION

Although there has been considerable progress in the use of administrative data for applied health research, the family justice field lags behind. Better use of administrative data are essential to enhance understanding of how the family justice system is working, as well as the characteristics of, and outcomes for, children and families. The Family Justice Data Partnership (FJDP) supports this aim through analyses of core family justice and linked datasets in the SAIL Databank (Secure Anonymised Information Linkage). Cafcass Cymru provide expert advice for children involved in family court proceedings in Wales, ensuring decisions are made in the best interests of the child. We provide an overview of Cafcass Cymru data. We also describe and illustrate linkage to administrative datasets within SAIL.

METHODS

Cafcass Cymru data was transferred to SAIL using a standardised approach to provide de-identified data with Anonymised Linking Fields (ALF) for successfully matched records. Three cohorts were created: all individuals involved in family court applications; all individuals with an ALF allowing subsequent health data linkage; and all individuals with a Residential Anonymised Linking Field (RALF) enabling area-level deprivation analysis.

RESULTS

Cafcass Cymru application data are available for child protection matters (public law, range 2011-2019, n=12,745), and child arrangement disputes (private law, range 2005-2019, n=52,023). An 80% data linkage match rate was achieved. 40% had hospital admissions within two years pre or post application; 54% had emergency department attendances and 61% had outpatient appointments. Individuals were more likely to reside in deprived areas regardless of law type.

CONCLUSION

Cafcass Cymru data can be accessed through the SAIL Databank. The FJDP will continue to enhance research opportunities for all to better understand the family justice system, and outcomes for those involved, such as health and wellbeing for children and family members.

Born into Care: characterising newborn babies and infants in care proceedings in England and Wales

Background/rationaleNations with advanced child protection systems place considerable emphasis on the developmental salience of infancy. However, this emphasis is not matched by any differentiated analysis of the timing of family court intervention in the lives of infants or the final legal order outcomes of these cases. This presentation shares findings from the first ever population profiling study of infants subject to care proceedings within the family justice system in England and Wales. AimTo estimate the proportion of all infant care proceedings cases issued within 7 days and 4 weeks of birth and describe case and infant characteristics; to calculate incidence rates over time and by local authority and family court region; to describe and compare legal order outcomes according to age. Methods/approachData was extracted from case management records produced by the Children and Family Court Advisory and Support Service (Cafcass) England and Wales. Records were first restructured to link infants to legal order outcome data and birth mother records. Incidence rates were calculated using ONS mid-year population estimates and annual live births. Within the SAIL Databank, Welsh infant records were linked to birth registration and community child health data to produce a fuller picture of infant characteristics in Wales. ResultsThe cohort we created comprised all infants recorded as subjects within care proceedings in England (2007/08-2016/17) and Wales (2011/12-2018/19). The study captured the high proportion of infant cases that are issued at/close to birth, but also marked regional and local authority variation in incidence rates. ConclusionHigh rates of adoption, particularly for babies born to mothers without a previous family court history, have prompted calls for new preventative solutions. The President of the Family (Court) Division in England has initiated a review of legal proceedings at birth.

A tale of multiple data sources: pathways and outcomes for infants who become looked after in Scotland

BackgroundPermanently Progressing? Building secure futures for children in Scotland is the first study in Scotland to investigate decision making, permanence, progress, outcomes and belonging for children who became looked after aged five or under. A significant proportion of these children become looked after away from home in the first few weeks after birth. It is important to understand more about the circumstances in which accommodation occurs, and the pathways and outcomes for these children. MethodsAnonymised child-level data (Children Looked After Statistics) was provided by the Scottish Government on the total cohort of 1,355 children in all 32 local authorities who started to be looked after away from home in 2012-13 aged five and under. Pathways and timescales to permanence were tracked between 2012-2016 using this administrative data. For a sub-group of 433 children, information on histories, progress and outcomes 3-4 years after they became looked after was gathered from surveys of adoptive parents, foster and kinship carers, and social workers. Results/conclusion This paper will discuss key findings from the study, in relation to those who became looked after soon after birth. Nearly half of those looked after away from home were under one year old when removed from parents, including 250 (18%) less than seven days old. These younger children were more likely to be looked after on an emergency basis, less likely to be placed with kinship carers, and more likely to have been adopted 3-4 years later, than those looked after when older. The complementary use of survey and administrative data is important. Evidence from the surveys of carers and social workers enhances our understanding of the circumstances around removal (including experience of maltreatment, removal of siblings, and parental substance misuse), and suggests that outcomes (emotional, behavioural and attachment) were generally better for children who were accommodated and placed with carers and adoptive parents at an earlier age and remained there.

The Nuffield Family Justice Observatory Data Partnership

Background Not enough is known about how the family justice system is working, the children and families using these services, and their wider outcomes beyond their involvement with the family court. The Nuffield Family Justice Observatory (FJO) Data Partnership, comprising a bespoke analysis platform hosted within the Secure Anonymised Information Linkage (SAIL) Databank and analytical teams at Lancaster and Swansea Universities, has been established to address this knowledge deficit. MethodsFamily justice data is being deposited in the SAIL Databank. Data are acquired using a standardised split-file approach, stored in an anonymised format and made available to projects as linked data using a unique encrypted project anonymised linkage field. These data can be augmented with a wealth of available health, education and other governmental/social routinely collected datasets, and future data acquired from other sources, for a range of research projects. ResultsChildren and Family Court Advisory and Support Service (Cafcass) Cymru data has been transferred to the SAIL Databank, and agreements to transfer the Cafcass England data are being finalised. Applications are now welcomed to use these data to enhance understanding of the family justice system and children and families involved with the family courts in public and private law. Access will be facilitated through the SAIL Databank, subject to relevant governance procedures. ConclusionWe will discuss the rationale of the Nuffield FJO Data Partnership, and how it aims to a) increase capacity and capability of researchers and data scientists utilising family justice and other relevant administrative datasets, b) improve understanding about the family justice system using data from the Cafcass in England and Wales, c) demonstrate the complexities and value of data linkage, and d) assist future policy and practice development. We will discuss matching rates for the Cafcass Cymru data and linkages that have been made to other datasets within the SAIL Databank. We will also set out the support available from the partnership to those wishing to access and utilise family justice data.

Protecting children during child protection research using administrative data

Background with rationaleChild protection systems aim to protect children from harm. Child protection research shares the same goal. However, the process of undertaking this research can present a risk. For child protection research using administrative data, children and families are at risk through breaches of privacy and identification, and further ethical issues of fair and necessary processing. This can be particularly challenging for countries such as Scotland, where smaller communities may mean children and families are more easily identifiable. For researchers and data gatekeepers alike, it is our duty to protect children in every way that we can throughout the process. Main AimThis paper aims to discuss with delegates the importance of protecting children during child protection research using administrative data, and some of the ways this can be done. Methods/ApproachThe paper will use an example of a recent research study which used administrative data from child protection systems in Scotland – Permanently Progressing? Building secure futures for children in Scotland. The methods used to protect children within this research and the lessons learned will be discussed. Input from delegates and the sharing of experiences will be most welcome throughout. Results and ConclusionChild protection research using administrative data often aim to inform and improve child protection systems. Such research can thereby enable more effective protection. However, such a research process raises its own child protection challenges, both to researchers and to the gatekeepers of this data. Despite this, although tricky at times to navigate, risks can be reduced through thoughtful care and consideration of these issues throughout the research process, from application to publication.

Linking two administrative datasets about looked after children: testing feasibility and enhancing understanding

Background with rationaleEvery year all 32 local authorities in Scotland provide information on looked after children in their area to the Scottish Government. This forms the basis for the annual Children Looked After Statistics (CLAS). Information is also collected by Scottish Children’s Reporter Administration (SCRA) on all children who are involved in the Children’s Hearings System. Until now these two data sets had never been linked. Main Aim To test the feasibility and success of the linkage on the basis that these datasets had not previously been linked, and if linkage was possible, use this data to enhance our understanding of the child and process factors associated with pathways to permanence or lack of permanence. Methods/ApproachVeterans were identified using the South London and Maudsley Biomedical Research Centre (SLaM) case register – a database holding secondary mental health care electronic records for the South London and Maudsley National Health Service Trust of 300,000 patients. We developed two methods. An NLP and machine learning tool were developed to automatically evaluate personal history statements written by clinicians. ResultsFor the first time, as part of the Permanently Progressing? Building secure futures for children in Scotland study, these two data sets were linked safely and successfully for 1,000 children who became looked after in 2012-13 when they were aged five and under. The linkage provided important new information for practitioners and policymakers. In this presentation we will focus on the key findings, such as what it told us about previous referrals and methodological insights regarding these data sets and their linkage. ConclusionThe data linkage process was complex and time-consuming but possible. The data we were able to link provided valuable information that enhanced our understanding of child and process factors.

Disentangling the effect of out-of-home care on child mental health

BACKGROUND

Children in out-of-home care are consistently found to have poor mental health compared to children in the general population. However, UK research has so far failed to disentangle the impact of the care system on children's mental health outcomes from the effects of the adverse circumstances that led to their admission to care.

OBJECTIVE

This research investigated the association between care placement and the presence of child mental health problems after controlling for children's pre-care experiences. It also identified factors associated with mental health problems among children in care.

PARTICIPANTS AND SETTING

The sample comprised three groups of children involved with child welfare services due to maltreatment, including children in out-of-home care (n = 122), reunified children (n = 82) and those who had never been in care (n = 159).

METHODS

The mental health of the children in the three groups was compared, using information collected from their parents/foster carers and social workers.

RESULTS

The odds of a child in out-of-home care having a mental health problem were not significantly higher than those of a child who had never been in care (AOR = 1.24; p = 0.462). However, the odds of a child in out-of-home care having reactive attachment disorder (RAD) were significantly higher than those of a child who had never been in care (AOR=1.92; p = 0.032).

CONCLUSIONS

These findings make an important contribution to international debates about whether placing children in care is beneficial or detrimental to their wellbeing, and highlight a range of inter-linking factors associated with the mental health of children in out-of-home care.

Permanently Progressing? Building Secure Futures for Children in Scotland: Pathways and outcomes for looked after children

BackgroundEach year many children in Scotland who cannot be cared for by their birth parents become looked after by Local Authorities. Where reunification is not an option, children need to be settled as soon as possible in safe and secure alternative homes. However, more research evidence is needed to guide the placement decisions that are so crucial to children’s wellbeing. ObjectivesThe Permanently Progressing? study aims to help identify factors that are associated with children achieving a permanent home. The study hopes to inform policy, planning and practice in relation to young children who cannot live with a birth parent. MethodsUsing the Children Looked After Statistics that are collected by the Scottish Government from all 32 Local Authorities, the study followed a group of children who became ‘looked after and accommodated’ at age five or under (n=1355) in 2012-13. Children’s pathways through the system over a four-year period were investigated and compared to another group of children aged five or under who became ‘looked after’ in the same year but remained with their birth parent(s) at this time (n=481). FindingsThe paper discusses children’s pathways through the looked after system, together with factors which may influence these pathways, such as age when becoming looked after, number and type of placements, and types of permanence achieved 3-4 years after becoming looked after. ConclusionsThis longitudinal analysis of administrative data offers unique insights into factors that may influence child welfare system responses to vulnerable children, which will be discussed, along with issues surrounding the difficulties associated with the definition and measurement of outcomes using these data.

Permanently Progressing? Building Secure Futures for Children in Scotland: Linking two national datasets about looked after children in Scotland to enhance understanding of pathways to permanence

BackgroundPermanently Progressing? is the first cohort study in Scotland aimed at understanding the factors associated with achieving settled and secure permanent homes for children. One part of this study involves analysing the national Children Looked After Statistics (CLAS) collected by the Scottish Government, to follow a group of children who became ‘looked after’ or ‘looked after and accommodated’ aged five or under. However, important decisions about these children are made at Children’s Hearings and the information about these decisions is stored in a database collated by the Scottish Children’s Reporters Administration (SCRA). ObjectivesAs these two datasets have never before been linked, the researchers aim to test the feasibility and success of this linkage. In addition, analysis of the linked dataset will allow both a description of the pathways of children who became looked after in 2012-13, and a comparison of the pathways for children who have achieved permanence at the end of year 4 to those who are on a pathway to permanence, and those still accommodated with no evident permanence plan. MethodsIn this project, the anonymised CLAS data obtained from the Scottish Government are being brought together with anonymised data held by SCRA, using probabilistic linkage methodologies. FindingsThe linkage and analysis of this data is currently underway and will be discussed during this presentation. ConclusionsIf successful, this linkage will serve as a pilot study for future research, help inform policy and practice, and enable the researchers to gain a more in-depth picture of a child’s journey through the system and the factors associated with children achieving permanence. The success of this linkage and challenges encountered will be discussed.

Mind-mindedness in parents of looked-after children

The studies reported here aimed to test the proposal that mind-mindedness is a quality of personal relationships by assessing mind-mindedness in caregiver-child dyads in which the relationship has not spanned the child's life or in which the relationship has been judged dysfunctional. Studies 1 and 2 investigated differences in mind-mindedness between adoptive parents (ns = 89, 36) and biological parents from the general population (ns = 54, 114). Both studies found lower mind-mindedness in adoptive compared with biological parents. The results of Study 2 showed that this group difference was independent of parental mental health and could not fully be explained in terms of children's behavioral difficulties. Study 3 investigated differences in mind-mindedness in foster carers (n = 122), parents whose children had been the subject of a child protection plan (n = 172), and a community sample of biological parents (n = 128). The level of mind-mindedness in foster carers and parents who were involved with child protection services was identical and lower than that in the community sample; children's behavioral difficulties could not account for the difference between the 2 groups of biological parents. In all 3 studies, nonbiological carers' tendency to describe their children with reference to preadoption or placement experiences was negatively related to mind-mindedness. These findings are in line with mind-mindedness being a relational construct. (PsycINFO Database Record

Transforming community health services for children and young people who are ill: a quasi-experimental evaluation

Background

Children’s community nursing (CCN) services support children with acute, chronic, complex and end-of-life care needs in the community.

Objectives

This research examined the impact of introducing and expanding CCN services on quality, acute care and costs.

Methods

A longitudinal, mixed-methods, case study design in three parts. The case studies were in five localities introducing or expanding services. Part 1: an interrupted time series (ITS) analysis of Hospital Episode Statistics on acute hospital admission for common childhood illness, and bed-days and length of stay for all conditions, including a subset for complex conditions. The ITS used between 60 and 84 time points (monthly data) depending on the case site. Part 2: a cost–consequence analysis using activity data from CCN services and resource-use data from a subset of families (n = 32). Part 3: in-depth interviews with 31 parents of children with complex conditions using services in the case sites and a process evaluation of service change with 41 NHS commissioners, managers and practitioners, using longitudinal in-depth interviews, focus groups and documentary data.

Findings

Part 1: the ITS analysis showed a mixed pattern of impact on acute activity, with the greatest reductions in areas that had rates above the national average before CCN services were introduced and significant reductions in some teams in acute activity for children with complex conditions. Some models of CCN appear to have more potential for impact than others. Part 2: the cost–consequence analysis covered only part of the CCN teams’ activity. It showed some potential savings from reduced admissions and bed-days, but none that was greater than the total cost of the services. Part 3: three localities implemented services as planned, one achieved partial service change and one was not able to achieve any service change. Organisational stability, finance, medical stakeholder support, competition, integration with primary care and visibility influenced the planning and implementation of new and expanded CCN services. Feeling supported to manage their ill child at home was a key outcome of using services for parents. Various service features contributed to this and were important in different ways at different times. Other outcomes included being able to avoid hospital care, enabling the child to stay in school, and getting respite. Although parents judged that care was of high quality when teams enabled them to feel supported, reassured and secure in managing their ill child at home, this did not depend on a constant level of contact from teams.

Limitations

Delays in service reconfigurations required adaptation of research activity across sites. Use of administrative data, such as Hospital Episode Statistics, for research purposes is technically difficult and imposed some limitations on both the ITS and the cost–consequence analyses.

Conclusions

Large, generic CCN teams that integrate acute admission avoidance for all children with support for children with complex conditions and highly targeted teams for children with complex conditions offer the possibility of supporting children more appropriately at home while also making some difference to acute activity. This possibility remains to be tested further.

Future work

Further work should refine the evidence on outcomes of services by looking at outcomes in promising models, value for money and measuring quality-based outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

Understanding care closer to home for ill children and young people

AIM

To gather evidence to support the implementation of standard six of the National Service Framework for Children, Young People and Maternity Services (Department of Health and Department for Education and Skills 2004), which states that care should be provided as close to home as possible.

METHODS

A mixed methods study comprising of a systematic review, a national survey of provision of care closer to home (CCTH), four in-depth, qualitative case studies and a cost analysis.

FINDINGS

The systematic review suggests that CCTH is no less clinically effective than hospital care. Services identified by the survey fall into three distinct models of provision. Case study data show that families preferred CCTH, but staff face difficulties at organisational and practice levels. Cost analysis suggests there can be cost savings with CCTH, but several factors influence these.

CONCLUSION

CCTH may be an effective and feasible option for children and young people who are ill.

Insulin--not always a life sentence: withdrawal of insulin therapy in non-insulin dependent diabetes

The extent of unnecessary insulin administration was assessed by reviewing the records of 350 patients with non-insulin-dependent diabetes (NIDDM). Subjects were included only if previously told that insulin therapy was to be permanent, and not if the need for insulin was known to be temporary (e.g. post-operatively). Fifty-one such patients were identified, 26 men and 25 women, mean age 59.5 (range 24-79) yr, with mean duration of diabetes 10.7 (1-34) yr. Insulin had been administered for a mean of 4.8 (0.3-34) yr in a mean daily dosage of 52.5 (12-280) units. Twenty-nine subjects (57%) were more than 110% of ideal body mass. Insulin therapy was ceased on an outpatient basis, using self blood glucose monitoring in nearly all cases. Mean duration of follow-up since ceasing insulin is 16 (3-48) months. Body mass in overmass subjects fell from (mean +/- S.D.) 92.3 +/- 20.5 to 82.1 +/- 17.8 kg (p less than 0.001). Mean HbA1 level fell from 12.0 +/- 2.2 to 11.0 +/- 2.0% (p less than 0.05). Sixteen patients are currently treated with diet, and 35 require diet and oral hypoglycemic agents. It appears that insulin therapy in NIDDM is often commenced for "dietary failure" rather than true secondary failure of oral hypoglycemic agents. Despite progressive increase in dosage, insulin may not improve diabetic control, and may cause weight gain. A management program of diet and exercise, based on self blood glucose monitoring allows reduction in dosage and withdrawal of insulin without hospitalization.(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetes education in Australia

Australia is a large continent of 15 mil lion people, 3% of whom have dia betes. The interior, or outback, has few facilities for medical care. Diabetes Centres are located in the large south- eastern coastal towns like Melbourne and Sydney. During the last ten years the growth in diabetes education has resulted in specialists in diabetes edu cation, week-long programs for both patients and professionals, and the formation of an Australian Diabetes Educators Association which has 300 members.